NIS Flashcards
1
Q
What is the focus of a safety reporting system?
A
Primary focus is on the patient, the event, and the process/system to identify opportunities for sustained improvement
NOT the individual who made the error
2
Q
What is professionalism defined as?
A
The conduct, aims, or qualities that characterize or mark a profession or a professional person.
Professionalism is regarded as the basis of medicine’s contract with society.
3
Q
What are the three fundamental principles of medical professionalism?
A
- Principle of primacy of patient welfare
- Principle of patient autonomy
- Principle of social justice
These principles guide the responsibilities of physicians in their practice.
4
Q
What is the principle of primacy of patient welfare?
A
Physicians must be dedicated to serving the interest of the patient, ensuring trust in the physician-patient relationship.
This principle must not be compromised by external pressures.
5
Q
What does the principle of patient autonomy entail?
A
Physicians must be honest and empower patients to make informed decisions about their treatment.
Patients’ decisions must be paramount within ethical practice.
6
Q
What is the principle of social justice in medicine?
A
The medical profession must promote the fair distribution of healthcare resources and eliminate discrimination in healthcare.
This principle emphasizes equity in healthcare access.
7
Q
What is the first professional responsibility outlined in the Physician Charter?
A
Commitment to professional competence.
Physicians must engage in lifelong learning to provide quality care.
8
Q
What does the commitment to honesty with patients involve?
A
Ensuring patients are fully informed before and after treatment, including prompt communication of medical errors.
This commitment also includes analyzing mistakes to improve practices.
9
Q
What is the commitment to patient confidentiality?
A
Physicians are responsible for safeguarding patient information, though public interest may occasionally override this commitment.
This is particularly relevant in the context of electronic information systems.
10
Q
What does the commitment to improving quality of care include?
A
- Maintaining clinical competence
- Collaborating with other professionals
- Reducing medical errors
- Increasing patient safety
- Optimizing care outcomes
Physicians should actively work to enhance the quality of healthcare delivery.
11
Q
What is the commitment to improving access to care?
A
Working towards uniform and adequate standards of care, while reducing barriers to equitable healthcare.
Barriers can include education, laws, finances, geography, or social discrimination.
12
Q
What is involved in the commitment to a just distribution of finite resources?
A
Physicians should develop evidence-based guidelines and avoid unnecessary tests and procedures to improve patient access to resources.
This commitment emphasizes cost-effective healthcare.
13
Q
What does the commitment to scientific knowledge entail?
A
Upholding scientific standards, promoting research, and ensuring the appropriate use of medical knowledge.
The integrity of this knowledge is based on scientific evidence.
14
Q
What is the importance of managing conflicts of interest?
A
Physicians must recognize, disclose, and manage conflicts that may arise from private gain or personal advantage.
This is crucial for maintaining trust in the physician-patient relationship.
15
Q
What does the commitment to professional responsibilities involve?
A
Collaborating to maximize patient care, respecting one another, and participating in self-regulation processes.
This includes addressing the performance of members who fail to meet standards.
16
Q
What are the professional limitations according to the ACR Bylaws?
A
Radiologists should be aware of their limitations and seek consultations when appropriate.
Limitations must be disclosed to patients and referring physicians.
17
Q
What is required when reporting illegal or unethical conduct?
A
Radiologists are expected to report any perceived illegal or unethical conduct of medical professionals.
This helps safeguard the public and the profession.
18
Q
What is the commitment to quality and safety activities?
A
Radiologists should participate in quality assurance and policy matters affecting care quality and safety.
This includes interpreting images and ensuring quality in care.
19
Q
What is quality in diagnostic imaging defined as? And it’s goals
A
The extent to which the right procedure is done in the right way, at the right time, with accurate communication of interpretations.
The goals are to maximize desired health outcomes and satisfy the patient.
20
Q
What are the two important dimensions of quality?
A
- Excellence
- Consistency
Quality care must be consistently delivered, not just excellent care occasionally.
21
Q
What is the purpose of monitoring performance in healthcare?
A
To ensure consistent quality of care.
Performance standards and measurements are crucial for achieving excellence.
22
Q
What does quality control (QC) refer to?
A
Measuring and testing performance elements to ensure standards are met and correcting poor quality instances.
An example of QC is reviewing errors in radiology reports.
23
Q
What is the difference between quality assurance (QA) and quality improvement (QI)?
A
- QA: Monitoring and ensuring performance quality, maintaining standards
- QI: Systematic improvement of performance quality over time
QI is proactive, while QA is often reactive.
24
Q
What is the Institute of Medicine’s definition of safe healthcare?
A
Avoiding injuries to patients from the care intended to help them.
Safety is a core component of quality healthcare.
25
What are the six core competencies established by the ACGME and ABMS?
* Practice-based Learning and Improvement
* Patient Care and Procedural Skills
* Systems-based Practice
* Medical Knowledge
* Interpersonal and Communication Skills
* Professionalism
## Footnote
These competencies are essential for modern medical practice.
26
What project did the National Academy of Sciences’ Institute of Medicine initiate in 1998?
Quality of Health Care in America project
## Footnote
Aimed to develop a strategy for improved quality of care in the U.S.
27
What was the title of the report published in 2000 by the IOM?
To Err is Human: Building a Safer Health System
## Footnote
First report from the Quality of Health Care in America project.
28
What range of in-hospital deaths per year were attributed to medical errors according to the 2000 IOM report?
44,000 to 98,000
## Footnote
Indicating a significant public health issue.
29
What are the projected total societal costs of medical errors as mentioned in the 2000 IOM report?
$17 billion to $29 billion
## Footnote
Highlighting the economic impact of medical errors.
30
Define medical error as per the 2000 IOM report.
Failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.
31
In which environments is the risk for medical errors highest?
High-acuity environments such as the intensive care unit, operating room, and emergency department.
32
List the fundamental factors contributing to medical errors identified in the 2000 IOM report.
* Decentralized nature of the healthcare delivery system
* Failure of licensing systems to focus on errors
* Impediment of the liability system to identify errors
* Failure of third-party providers to incentivize safety
33
What is the recommended strategy for decreasing medical errors according to the 2000 IOM report?
Design safety into systems and processes of care.
34
What report was issued by the IOM in 2015?
Improving Diagnosis in Health Care
## Footnote
Focused on diagnostic error as a continuation of the 2000 report.
35
Define diagnostic error as per the 2015 IOM report.
Failure to establish an accurate and timely explanation of the patient’s health problem(s) or communicate that explanation to the patient.
36
Why is quick establishment of a correct diagnosis critical?
It is essential for safe and effective patient care.
37
What percentage of postmortem exams were associated with diagnostic errors that might have affected outcomes?
10%.
38
What approach did the 2015 IOM report recommend for understanding and improving diagnostic errors?
Objective, nonpunitive efforts to learn from errors and improve systems and processes.
39
How many specific recommendations for improving diagnostic processes did the 2015 IOM report make?
Eight.
40
What is one recommendation from the 2015 IOM report concerning healthcare professional education?
Enhance healthcare professional education and training in the diagnostic process.
41
What role do radiologists and pathologists play in the diagnostic team according to the 2015 IOM report?
Integral part of the diagnostic team.
42
What is human factors engineering?
A discipline that identifies and addresses problems by considering human strengths and limitations in system design.
43
What does human factors engineering focus on?
How systems work in actual practice with real human beings.
44
In which industries has human factors engineering long been used to improve safety?
* Aviation
* Nuclear power
45
What is the purpose of standardization in human factors engineering?
To increase reliability, improve information flow, and minimize cross-training needs.
46
Define effective communication in a healthcare context.
Meaningful exchange of information resulting in shared understanding.
47
What is a High Reliability Organization (HRO)?
An organization that manages its high-stress, high-risk environment mindfully to minimize errors.
48
What are the three elements of anticipation in HROs?
* Preoccupation with failure
* Reluctance to simplify
* Sensitivity to operations
49
What are the two elements of containment in HROs?
* Commitment to resilience
* Deference to expertise
50
What does the skill-rule-knowledge (SRK) model classify?
The cognitive mode in which an individual commits an error.
51
What type of errors are considered skill-based actions?
Actions performed automatically, requiring little conscious attention.
52
What type of errors are considered knowledge-based actions?
Actions requiring a high level of concentration in new situations.
53
What is the concept of safety culture?
A commitment to safety at all levels of an organization.
54
What are the key features of a culture of safety?
* Acknowledgment of high-risk activities
* A blame-free environment
* Encouragement of collaboration
* Organizational commitment of resources
55
What is the authority gradient?
A hierarchical structure that can undermine safety culture and reporting.
56
What is the just culture model proposed by David Marx?
Distinguishes between human error, at-risk behavior, and reckless behavior.
57
What is a 'second victim' in healthcare?
A healthcare worker traumatized by an error or adverse patient event.
58
What should the focus of an investigation be when an error occurs?
Identify opportunities for sustainable improvement
## Footnote
The individual who made the error should not be the focus unless acting recklessly.
59
What is the term used for a healthcare worker traumatized by an error or adverse patient event?
Second victim
## Footnote
This term highlights the psychological impact on the healthcare worker involved.
60
What feelings do 'second victims' often experience?
* Guilt
* Sorrow
* Anxiety
## Footnote
They may also exhibit signs similar to post-traumatic stress disorder.
61
What have many hospitals begun to develop for 'second victims'?
Internal programs to identify, console, and advocate for individuals
## Footnote
These programs aim to support healthcare workers affected by errors.
62
True or False: The reporting system should be used to instigate punitive action.
False
## Footnote
The focus should be on improvement, not punishment.
63
What is human error in the Just Culture Model?
A product of our current system design and our behavioral choices
## Footnote
Human error is often viewed as an unavoidable outcome influenced by the system in which individuals operate.
64
What are the management strategies for human error?
* Modify available choices
* Change processes/workflows
* Improve training programs
* Redesign system or facility
## Footnote
These strategies aim to create an environment that minimizes human error through better system design and training.
65
Define at-risk behavior in the context of the Just Culture Model.
A choice where the risk is believed to be insignificant or justified
## Footnote
At-risk behavior often stems from a misjudgment of the actual risk involved in a situation.
66
What are the management strategies for at-risk behavior?
* Counsel individual
* Better incentivize correct behavior
* Modify processes, training, etc. as needed
## Footnote
These strategies focus on guidance and incentives to encourage safer choices.
67
What characterizes reckless behavior?
A conscious disregard for a substantial and unjustifiable risk
## Footnote
Reckless behavior is often seen as willful negligence and poses a serious threat to safety.
68
What are the management strategies for reckless behavior?
* Remediate or remove from the environment
* Take punitive action as warranted
## Footnote
Addressing reckless behavior often involves strict consequences to deter future occurrences.
69
What are the two aspects of quality improvement activities?
1) Frequent small improvement efforts
2) Dedicated improvement projects
70
What is the objective of a daily management system (DMS)?
To facilitate communication and coordination within and across organizational units
71
What types of roles does a DMS allow for coordination and communication?
1) Radiologists, technologists, nurses, etc.
2) Front line staff, managers, leaders
3) Radiology department and other units
72
What is a huddle in the context of a DMS?
A brief structured meeting to review recent occurrences, current status, and future anticipations
73
What are first-tier huddles?
Huddles held within local units involving all frontline staff on service for the day
74
What does the goal and metrics review help organizations to do?
Focus on making tangible progress toward better fulfillment of the organization’s missions
75
What topics are typically reviewed in a daily readiness assessment?
1) Methods
2) Equipment
3) Supplies
4) Associates
76
What is the purpose of the problem management and accountability cycle?
To encourage continuous problem solving and track problems with an owner and expected resolution date
77
What is the importance of regular follow-up in a DMS?
It increases the likelihood that assignments will be completed or revised as needed
78
What is a core tenet of effective management regarding workplace visits?
To see what is happening in the workplace to truly understand it
79
What are project-based improvement methods designed for?
To address problems that are too difficult to solve using routine daily problem-solving methods
80
What does the term 'problem' refer to in the context of improvement?
1) Something difficult to deal with
2) Something to be worked out or solved
81
What is the first step in solving a problem in improvement?
Clearly defining the problem
82
What roles are typically included in a project team?
1) Project Sponsor
2) Project Leader
3) Project Participants
4) Project Coach
83
What is the role of the Project Sponsor?
To provide organizational oversight and support, removing barriers as they arise
84
What is the purpose of assessing current performance in improvement projects?
To deeply understand the process through observation and documentation
85
What are performance measures used for?
To assess performance in an objective and repeatable fashion
86
What does the acronym 'SMART' stand for in establishing a specific goal?
Specific, Measurable, Achievable, Relevant, Time-bound
87
What is a cause-and-effect diagram also known as?
Fishbone diagram
88
What does the Pareto principle state?
A few causes are usually responsible for the majority of the problems
89
What is the Plan-Do-Study-Act (PDSA) cycle?
A process of iteratively testing, refining, and validating process changes
90
What is the goal of the PDSA cycle?
To test a hypothesis of how a process change will lead to a desired outcome
91
What strategies can sustain improvements in performance?
1) Regular measurement and feedback
2) Using handoffs to enforce standards
3) Stopping the process for problems
4) Embedding checks into the process
5) High-reliability solutions
92
What is defined as a project?
A temporary group activity designed to produce a unique product, service, or result
93
What is patient identification critical for?
To ensure the right patient receives the right treatment and reduce unnecessary exposure
94
What identifiers should be used before every procedure?
At least two patient identifiers such as name, ID number, or date of birth
95
What are the four levels of sedation defined by the Joint Commission?
1) Minimal Sedation/anxiolysis
2) Moderate Sedation/Analgesia
3) Deep Sedation/Analgesia
4) General anesthesia
96
What is the state of consciousness during light sedation?
A state where the patient responds to verbal commands, cognitive function and coordination may be impaired, but ventilatory and cardiovascular functions are unaffected.
97
Define Moderate Sedation/Analgesia.
A mildly depressed level of consciousness where the patient can maintain protective reflexes and a patent airway, and can be aroused by physical or verbal stimulation.
98
What characterizes Deep Sedation/Analgesia?
A drug-induced depression of consciousness where the patient cannot be easily aroused but responds to painful stimulation. Ventilators fxn may be impaired but cardiovascular fxn is maintained
99
What is General Anesthesia?
A controlled state of unconsciousness with a complete loss of protective reflexes, including the ability to maintain a patent airway independently or respond to painful stimulation
100
True or False: Sedation levels are a continuum.
True
101
List some risk factors that may increase the likelihood of an adverse outcome from sedation.
* Congenital or acquired abnormalities of the airway
* Liver failure
* Lung disease
* Congestive heart failure
* Symptomatic brain stem dysfunction
* Apnea or hypotonia
* History of adverse reactions to sedating medications
* Morbid obesity
* Severe gastroesophageal reflux
102
What does the American Society of Anesthesiologists (ASA) Physical Status Classification assess?
It assesses the physical status of patients on a six-level scale:
Class I (normal healthy patient), Class II (mild systemic disease), Class III (severe systemic disease), Class IV (severe systemic disease constant threat to live), Class V (patient not expected to survive without operation), Class VI (declared brain-dead patient).
103
What is the minimum monitoring required during sedation?
* Level of consciousness
* Respiratory rate
* Pulse oximetry
* Blood pressure
* Heart rate
* Cardiac rhythm
104
What is required for informed consent in invasive image-guided procedures?
Patients have the right to be informed about procedures and may request to speak with a radiologist.
105
Fill in the blank: Informed consent is a _______ and not just the act of signing a document.
[process]
106
What are the elements of informed consent?
* Purpose and nature of the intended procedure
* Method of performing the procedure
* Likely risks, complications, and expected benefits
* Risks of not proceeding
* Reasonable alternatives to the proposed procedure
* Right to decline the proposed procedure
107
Who can provide consent when a patient is unable to do so?
A healthcare representative, legal guardian, or appropriate family member.
108
What is the Universal Protocol?
A three-part process that includes preprocedure verification, marking the procedure site, and performing a preprocedure time out.
109
What is the purpose of preprocedure verification?
To ensure all relevant information and equipment are available, correctly labeled, and matched to the patient’s identifiers.
110
When should a procedure site be marked?
When there is more than one possible location for the procedure and when incorrect location could harm the patient.
111
What is the preprocedure time out?
A standardized time out conducted immediately before an invasive procedure to confirm patient identity, site, and procedure.
112
What does hand hygiene include?
* Handwashing with soap and water
* Antiseptic hand wash
* Antiseptic hand rub (alcohol-based)
* Surgical hand antisepsis
113
When should alcohol-based hand sanitizers be used?
When hands are not visibly dirty.
114
What is Root Cause Analysis (RCA)?
A structured method used to analyze serious adverse events to decrease the likelihood of recurrence.
115
What are active errors in RCA?
Errors occurring at the interface between humans and a complex system.
116
What are latent conditions in RCA?
Hidden problems within healthcare systems that increase the likelihood of an adverse event.
117
What should an RCA culminate in?
An analysis of issues to decrease the likelihood of recurrence and a plan for addressing those issues.
118
True or False: Immediate interventions in RCA address the root cause.
False
119
What are the three unique magnetic fields in MRI?
1. Static magnetic field (B0)
2. Time-varying radiofrequency magnetic field (B1)
3. Time-varying gradient magnetic field (dB/dt)
## Footnote
These fields contribute to specific MR safety challenges.
120
Who are the stakeholders that need to be ensured safety in the MR environment?
1. Patients
2. Research subjects
3. MRI personnel
4. Visitors
## Footnote
Greater risk is assumed for non-MR personnel.
121
What is the role of the MR Medical Director (MRMD)?
The MRMD assumes ultimate responsibility for a site’s operational MR safety and the safe execution of all MR examinations.
## Footnote
They also appoint MR safety officers and experts, maintain policies, and investigate safety adverse events.
122
What are the four zones defined in MR safety?
1. Zone I: Unrestricted access
2. Zone II: Interface between unrestricted and restricted zones
3. Zone III: Potential danger from unscreened people
4. Zone IV: MR scanner magnet room, highest risk area
## Footnote
Each zone has different access restrictions and safety measures.
123
What characterizes Level 1 MR personnel?
Level 1 personnel have passed the facility’s MR safety education requirements but are not independently responsible for the safety of others in Zone IV.
## Footnote
They ensure their own safety and that of others in less restricted areas.
124
What is the significance of the 9 gauss line?
The 9 gauss line is the point at which the magnetic field begins to affect electromagnetic devices such as pacemakers.
## Footnote
It should be marked for safety, particularly if it extends beyond the MR scanner room.
125
What are the classifications of medical devices in relation to MR safety?
1. MR Safe
2. MR Unsafe
3. MR Conditional
## Footnote
Each classification has specific requirements for safe scanning.
126
What are the recommendations for changing patients before an MRI?
All MR patients are recommended to change into MR safe gowns or scrubs to minimize the risk of burns from metallic fibers in clothing.
## Footnote
This includes avoiding street clothes during scanning.
127
What is a quench in MRI?
A quench occurs when heating of a segment of the electromagnetic coils makes them no longer superconducting, leading to a rapid change of state of liquid helium into gas.
## Footnote
This can create hazards such as asphyxiation due to displaced oxygen.
128
True or False: MRI exposure without gadolinium-based contrast media has been shown to have detrimental effects on the developing fetus.
False
## Footnote
No special consideration is recommended during pregnancy for noncontrast MRI up to 3T.
129
What precautions should be taken to prevent burns from RF fields during MRI?
1. Maintain distance between skin and bore surface
2. Use insulating pads
3. Avoid skin-to-skin contact
## Footnote
Special care should be taken with patients who may have folds of skin that could contact each other.
130
What should be done if a medical device is determined to be ferromagnetic and MR unsafe?
It must be appropriately secured or tethered at all times and be under the supervision of trained MR personnel.
## Footnote
This is to prevent projectile injuries and other hazards.
131
Fill in the blank: The _______ is the highest risk area in an MR environment.
Zone IV
## Footnote
This zone includes the MR scanner magnet room.
132
What does the MR safety screening process begin with?
A focused history to identify potential metallic foreign objects and medical implants.
## Footnote
This may include reviewing existing radiographs or medical records.
133
What is the risk associated with cold helium gas flooding a room?
It forms a fog, making it impossible to see
## Footnote
This can create a significant risk of asphyxiation.
134
What should emergency procedures include in the case of a quench?
Immediate evacuation of Zone IV
## Footnote
Due to the risks associated with a quench.
135
How can a magnet quench be initiated?
By pressing a quench button
## Footnote
This is necessary in emergencies when the magnetic field must be shut off immediately.
136
What are the two classifications of iodinated contrast media?
Ionic and nonionic
## Footnote
Additionally, they can be classified as monomeric or dimeric.
137
What characterizes ionic contrast media?
They dissociate into two particles in solution
## Footnote
An anion with the tri-iodinated benzene ring and a cation (sodium or methylglucamine).
138
What is the osmolality of ionic monomeric contrast media compared to human serum?
Roughly four times that of human serum
## Footnote
They are referred to as high-osmolality contrast media.
139
What is the osmolality of nonionic monomeric contrast media compared to high-osmolality contrast media?
About half the osmolality of high-osmolality contrast media
## Footnote
And roughly twice that of serum.
140
What is the osmolality of nonionic dimeric contrast media referred to?
Iso-osmolality contrast media
## Footnote
They have similar osmolality to that of plasma.
141
Name one low-osmolality iodinated contrast agent approved for intravascular use.
Iohexol (Omnipaque®)
## Footnote
Other examples include iopamidol, iopromide, ioversol, and ioxilan.
142
What percentage of patients experience no adverse effects after receiving iodinated contrast media?
Most patients
## Footnote
Adverse reactions can occur, but the majority have none.
143
What types of acute adverse reactions are categorized for iodinated contrast media?
Physiologic or allergic-like
## Footnote
Physiologic reactions are dose related.
144
What are examples of mild physiologic reactions to iodinated contrast media?
Nausea, vomiting, flushing, warmth, chills
## Footnote
Other symptoms include headache, anxiety, altered taste, mild hypertension.
145
What characterizes moderate allergic-like reactions?
Diffuse hives, diffuse erythema, facial edema without dyspnea
## Footnote
Symptoms can include wheezing with mild or no hypoxia.
146
What are severe reactions to iodinated contrast media associated with?
Potentially life-threatening symptoms
## Footnote
Such as arrhythmia, seizures, pulmonary edema, cardiopulmonary arrest.
147
What is the incidence of severe life-threatening allergic-like reactions?
Estimated to be 0.01% to 0.04% of injected patients
## Footnote
Severe reactions are extremely rare.
148
What factors increase the likelihood of an adverse reaction to contrast media?
History of prior allergic-like reactions, other allergies, asthma
## Footnote
Patients with severe chronic kidney disease or acute kidney injury may also be at risk.
149
What is the recommended action for patients with thyroid cancer or hyperthyroidism before radioiodine treatment?
Do not receive iodinated contrast in the 4 to 6 weeks prior
## Footnote
This prevents saturation of the thyroid gland.
150
What is the purpose of premedication before administering contrast media?
To reduce the likelihood of an acute allergic-like reaction
## Footnote
Considered for high-risk patients.
151
What is a common adult premedication regimen for contrast media?
50 mg of prednisone 13, 7, and 1 hour(s) before injection
## Footnote
Also includes 50 mg of diphenhydramine 1 hour before injection.
152
What is postcontrast acute kidney injury (PC-AKI)?
Sudden deterioration in renal function after contrast media administration
## Footnote
Clinical onset detectable within 24 to 48 hours.
153
How is contrast-induced nephropathy (CIN) defined?
Deterioration in renal function caused by iodinated contrast media
## Footnote
CIN is a subset of PC-AKI.
154
What is the estimated likelihood of developing CIN in patients with eGFR < 30 mL/min/1.73 m2?
Much more likely compared to those with higher eGFR
## Footnote
CIN is less common in patients with eGFR ≥ 45 mL/min/1.73 m2.
155
What condition is most likely to develop in patients with severe CKD or AKI after contrast media administration?
CIN
## Footnote
CIN stands for Contrast-Induced Nephropathy.
156
What is the estimated glomerular filtration rate (eGFR) threshold below which CIN is likely to develop?
eGFR < 30 mL/min/1.73 m2
## Footnote
This indicates severe chronic kidney disease.
157
What is the historical definition of PC-AKI?
An absolute increase in serum creatinine of at least 0.5 mg/dL, or a 25% to 50% increase in baseline serum creatinine.
158
What are the three criteria for diagnosing AKI according to the Acute Kidney Injury Network (AKIN)?
* Absolute serum creatinine increase of at least 0.3 mg/dL
* Percentage increase in serum creatinine of at least 50% (1.5-fold above baseline)
* Reduction in urine output to 0.5 mL/kg/h for at least 6 hours
159
What is the typical clinical course of PC-AKI after contrast media administration?
A rise in serum creatinine beginning within 24 hours, peaking at about 4 days, and usually returning to baseline by 7 to 10 days.
160
What are some conditions that may predispose patients to develop AKI?
* Diabetes mellitus
* Dehydration
* Cardiovascular disease
* Diuretic use
* Advanced age
* Multiple myeloma
* Hypertension
* Hyperuricemia
161
What is the risk associated with administering large or multiple doses of contrast media within 24 to 48 hours?
Increased risk of AKI.
162
What is the most widely accepted strategy for minimizing the risk of PC-AKI in at-risk patients?
IV volume expansion with isotonic fluids, such as 0.9% saline or Lactated Ringer’s solution.
163
What volume expansion protocol is suggested before and after contrast administration?
100 mL/h for 6 to 12 hours before and continued for 4 to 12 hours after.
164
What is the recommended action for patients receiving metformin who develop AKI?
Withhold metformin for 48 hours after contrast media administration.
165
What is the risk of administering iodinated contrast media to pregnant patients?
No evidence of harm to the fetus.
166
What percentage of administered contrast media enters the milk of breastfeeding mothers?
1%
## Footnote
Of this, only 1% is absorbed by the infant.
167
What complication can occur due to extravasation of IV-administered iodinated contrast media?
Edema, erythema, and tenderness at the site of extravasation.
168
What is the reported overall rate of extravasation with power injection for CT?
0.1% to 1.2%.
169
What should be done immediately after extravasation occurs?
Elevate the affected extremity above the level of the heart.
170
What are signs that may indicate a severe extravasation injury?
* Progressive swelling or pain
* Decreased finger mobility
* Altered tissue perfusion
* Change in sensation
* Skin ulceration or blistering
171
What is the most common severe injury associated with extravasation of nonionic contrast media?
Compartment syndromes.
172
What should be monitored in patients after contrast extravasation?
Ensure minor symptoms remain stable or improve.
173
What is a potential consequence of severe extravasation injuries?
Compartment syndrome or tissue necrosis.
174
What is the recommended management for extravasation injuries?
Cold compresses or ice packs can be applied.
175
What is the chemical moiety that binds gadolinium in most MRI contrast agents?
Chelate
176
What are the two classifications of gadolinium-based contrast media (GBCM)?
* Linear or Macrocyclic
* Ionic or Nonionic
177
Which type of GBCM generally has more stable binding of gadolinium?
Macrocyclic GBCM
178
How do nonionic linear GBCM compare to ionic linear GBCM in terms of stability?
Nonionic agents are less stable than ionic agents
179
How frequently do acute adverse reactions to GBCM occur compared to iodinated contrast media?
Approximately two to four times less frequently
180
What are some common mild and non-allergic-like reactions to GBCM?
* Coldness at injection site
* Nausea
* Headache
* Warmth or pain at injection site
* Paresthesias
* Dizziness
181
What are the most frequent allergic-like symptoms associated with GBCM?
* Rash
* Hives
* Urticaria
182
What unique side effect is associated with gadoxetate disodium (Eovist®)?
Transient tachypnea
183
What patient factors increase the risk for adverse reactions to GBCM?
* Previous reactions to GBCM
* Other allergies
* Asthma
184
What is the FDA recommendation for patients with prior allergic-like reactions to GBCM?
Use of a different gadolinium compound for reinjection is recommended
185
What is the FDA classification for GBCM regarding pregnancy?
Pregnancy class C drugs
186
What potential risk does GBCM pose to a fetus during pregnancy?
They may increase the risk of dissociation from the chelate of the potentially toxic gadolinium ion
187
What percentage of administered GBCM is excreted into the milk of breastfeeding mothers?
0.04%
188
What is Nephrogenic Systemic Fibrosis (NSF)?
A fibrosing disease most evident in skin and subcutaneous tissues
189
What is a common symptom of NSF?
Skin thickening with plaque formation
190
In which patients does NSF occur nearly exclusively?
Patients with severe CKD (eGFR < 30 mL/min/1.73 m2) or AKI exposed to GBCM
191
Which GBCM are considered high-risk for developing NSF?
* Gadodiamide (Omniscan®)
* Gadoversetamide (OptiMark®)
* Gadopentetate dimeglumine (Magnevist®)
192
What are the lower-risk GBCM associated with NSF?
* Gadobenate dimeglumine (MultiHance®)
* Gadobutrol (Gadavist®)
* Gadoterate meglumine (Dotarem®, Clariscan®)
* Gadoteridol (ProHance®)
193
What mechanism is speculated to cause NSF?
Dissociation of the gadolinium ion from its chelate in vivo
194
What precaution is recommended to avoid NSF in patients with severe CKD?
Avoid high-risk GBCM
195
What is the FDA's stance on using high-risk GBCM when eGFR is less than 30 mL/min/1.73 m2?
High-risk GBCM are absolutely contraindicated
196
Is immediate post-MRI dialysis proven to reduce the risk of NSF?
No proof exists that it reduces the risk
197
What is the risk for NSF associated with Gadopentetate dimeglumine (Magnevist®)?
High risk for NSF
## Footnote
NSF stands for Nephrogenic Systemic Fibrosis, a serious condition associated with gadolinium-based contrast agents.
198
What type of contrast agent is Gadopentetate dimeglumine (Magnevist®)?
Ionic, linear
199
What is the risk for NSF associated with Gadobenate dimeglumine (MultiHance®)?
Low risk for NSF
200
What type of contrast agent is Gadobenate dimeglumine (MultiHance®)?
Ionic, linear
201
What type of contrast agent is Gadoxetate disodium (Eovist®)?
Ionic, linear
202
What is the risk for NSF associated with Gadodiamide (Omniscan®)?
High risk for NSF
203
What type of contrast agent is Gadodiamide (Omniscan®)?
Nonionic, linear
204
What is the risk for NSF associated with Gadoteridol (ProHance®)?
Low risk for NSF
205
What type of contrast agent is Gadoteridol (ProHance®)?
Nonionic, macrocyclic
206
What is the risk for NSF associated with Gadobutrol (Gadavist®)?
Low risk for NSF
207
What type of contrast agent is Gadobutrol (Gadavist®)?
Nonionic, macrocyclic
208
What is the risk for NSF associated with Gadoterate meglumine (Dotarem®) (Clariscan®)?
Low risk for NSF
209
What type of contrast agent is Gadoterate meglumine (Dotarem®) (Clariscan®)?
Ionic, macrocyclic
210
What is nephrogenic systemic fibrosis (NSF)?
A fibrosing disease primarily affecting the skin and subcutaneous tissues, but may also involve other organs.
## Footnote
NSF may impact the lungs, esophagus, heart, and skeletal muscles.
211
What are the initial symptoms of NSF?
Skin thickening with plaque formation.
212
What are potential severe outcomes of NSF?
Contractures, joint immobility, and occasionally fatality.
213
In which patient population does NSF occur nearly exclusively?
Patients with severe chronic kidney disease (CKD) or acute kidney injury (AKI) exposed to gadolinium-based contrast media (GBCM).
214
What is the eGFR threshold associated with NSF risk?
eGFR < 30 mL/min/1.73 m2.
215
What factors complicate the identification of the GBCM responsible for NSF?
Patients often receive multiple different MR contrast agents.
216
What is the difference between 'confounded' and 'unconfounded' GBCM exposure?
'Confounded' refers to multiple GBCM exposures; 'unconfounded' refers to exposure to a single agent.
217
Which GBCM are considered high-risk for NSF?
* Gadodiamide (Omniscan®)
* Gadoversetamide (OptiMark®)
* Gadopentetate dimeglumine (Magnevist®)
218
What is the relationship between GBCM dosage and NSF risk?
Higher doses and multiple doses of high-risk GBCM increase the likelihood of NSF.
219
Which GBCM are categorized as lower-risk for NSF?
* Gadobenate dimeglumine (MultiHance®)
* Gadobutrol (Gadavist®)
* Gadoteratemeglumine (Dotarem® and Clariscan®)
* Gadoteridol (ProHance®)
220
What is the risk level of NSF associated with gadoxetate disodium (Eovist®)?
Probably very low risk.
221
What additional risk factors have been suggested for NSF development?
* Metabolic acidosis
* Increased iron, calcium, and/or phosphate levels
* High-dose erythropoietin therapy
* Immunosuppression
* Vasculopathy
* Acute pro-inflammatory events
* Infection
222
What is the proposed mechanism behind NSF?
Speculated to result from dissociation of the gadolinium ion from its chelate in vivo.
223
What is 'transmetallation' in the context of NSF?
The process where a different ion replaces the gadolinium ion within the chelate, freeing the toxic gadolinium atom.
224
What precautions have been taken to manage the risk of NSF?
Avoiding high-risk GBCM in patients with severe CKD or AKI.
225
What is the FDA's stance on high-risk GBCM use in patients with eGFR < 30 mL/min/1.73 m2?
High-risk GBCM are absolutely contraindicated.
226
Does immediate post-MRI dialysis reduce the risk of NSF?
No proof that it reduces risk.
227
In which body parts is gadolinium retained post-GBCM administration?
* Skeleton
* Brain (globus pallidus and dentate nucleus)
228
How does gadolinium retention differ between linear and macrocyclic agents?
Retention is greater with linear agents.
229
What are the neurologic effects of gadolinium accumulation?
No evidence of adverse neurologic effects has been found.
230
What is crucial for managing allergic-like reactions during imaging?
Rapid recognition, patient assessment, and diagnosis.
231
What should be monitored in patients experiencing allergic-like reactions?
Vital signs and patient consciousness.
232
How long do mild reactions usually last?
20 to 30 minutes.
233
What is the treatment for hives (urticaria) during a contrast reaction?
If symptomatic, administer diphenhydramine (Benadryl®) or fexofenadine (Allegra®).
234
What is the recommended action for diffuse erythema in a contrast reaction?
Preserve IV access, monitor vitals, and administer oxygen.
235
What should be done for laryngeal edema in a contrast reaction?
Preserve IV access, monitor vitals, administer oxygen, and give epinephrine.
236
What is the management for bronchospasm in a contrast reaction?
Preserve IV access, administer oxygen, and give beta-agonist inhaler albuterol.
237
What is the first step in managing hypotension in a contrast reaction?
Preserve IV access and monitor vitals.
238
What is the pediatric dosing for diphenhydramine (Benadryl®)?
1 mg/kg up to a maximum of 50 mg.
239
What is the maximum single dose of epinephrine for pediatric patients over 30 kg?
0.3 mL (0.3 mg) of 1 mg/mL (1:1000 dilution).
240
What symptoms may indicate a severe allergic-like reaction?
Hypotension, tachycardia, and respiratory distress.
241
What is the role of IV corticosteroids in allergic-like reactions?
Not useful for acute treatment, but may prevent short-term recurrence.
242
What should be done if a patient becomes unresponsive and pulseless?
Check for responsiveness, activate emergency response, and perform CPR.
243
What is the basis for physician services and procedures reimbursement?
Fee-for-service basis
## Footnote
This system traditionally forms the foundation of physician reimbursement.
244
What is the shift in reimbursement models for primary care?
From volume-based to value-based payments
## Footnote
Value-based payments require attainment of certain quality measures.
245
What is a Current Procedural Terminology code (CPT)?
A unique code assigned to each service or procedure provided by a physician.
246
Who maintains the CPT code set?
The American Medical Association (AMA) CPT Editorial Panel.
247
What does the Relative Value Unit (RVU) represent?
The value assigned to each CPT code based on the Resource Based Relative Value Scale.
248
What is the role of the AMA RBRVS Update Committee (RUC)?
Makes recommendations to CMS for RVU valuation for each CPT code.
249
What three components make up the total RVUs for a service or procedure?
* Work RVU
* Practice expense RVU
* Malpractice RVU
250
How is actual reimbursement calculated?
Payment = RVU x Conversion Factor (CF).
251
What is the Conversion Factor (CF)?
A multiplier set annually by CMS to determine actual reimbursement.
252
What defines medical necessity according to CMS?
Healthcare services needed to prevent, diagnose, or treat an illness, injury, condition, or disease.
253
What coding system must diagnosis codes adhere to for reimbursement?
International Classification of Diseases (ICD) system.
254
What is the purpose of the Radiology Coding Certification Board?
To credential professional medical imaging coders.
255
What is the importance of documentation in radiology services reimbursement?
Adequate documentation within the physician report is crucial for coding and reimbursement.
256
What is preauthorization in the context of radiology services?
A requirement by payers for approval before performing elective outpatient advanced imaging services.
257
What is Clinical Decision Support (CDS) software used for?
To score appropriateness of imaging orders in specific clinical conditions.
258
What is the purpose of the False Claims Act (FCA)?
To protect the government from overcharges or substandard goods or services.
259
What can be the consequence of a false claim ruling?
Fines of up to three times the billed amount plus $11,000 per claim filed.
260
What does HIPAA stand for?
Health Insurance Portability and Accountability Act of 1996.
261
What is protected health information (PHI)?
Individually identifiable health information.
262
What are the primary goals of the HIPAA rules?
* Protect PHI
* Allow flow of information for quality healthcare
263
What must be included in the research informed consent process?
* Providing adequate information
* Allowing time for consideration
* Responding to questions
* Ensuring comprehension
* Obtaining voluntary agreement
* Providing ongoing information
264
What does an Institutional Review Board (IRB) do?
Reviews and monitors biomedical research involving human subjects.
265
What are the four elements required for a medical malpractice lawsuit?
* Established duty
* Breach of duty
* Causation
* Damages
266
What is the average indemnity payment in malpractice cases for radiologists?
$480,000.
267
What is the difference between 'claims-made' and 'occurrence' malpractice insurance policies?
* Claims-made: protects while the policy is active, usually requires tail
* Occurrence: covers any claim for events during the coverage period even if the claim is filed after the policy lapses
268
What types of activities can HIPAA allow disclosure of PHI without individual authorization?
* Delivery of care
* Payment activities
* Healthcare operations
269
What is the Nuremberg Code?
The first international codification of minimal expectations for ethical research involving human subjects.
270
What are the identifiers included in the definition of PHI?
* Names
* Geographic subdivisions
* Dates related to an individual
* Phone numbers
* Fax numbers
* Email addresses
* Social Security numbers
* Medical record numbers
* Health plan beneficiary numbers
* Account numbers
* License numbers
* Vehicle identification numbers
* Device identifiers
* URLs
* IP addresses
* Biometric identifiers
* Photographs
* Any unique identifier or characteristic
271
What are the four elements required for medical malpractice lawsuits based on negligence?
* Established duty to a patient
* Breach of duty
* Causation
* Resulting damages
## Footnote
The definition of standard of care varies by jurisdiction.
272
What constitutes a breach of duty in medical malpractice?
Failure to meet the standard of care
## Footnote
The standard of care is determined by how a reasonable physician of a similar specialty would act in similar circumstances.
273
In malpractice claims, what must be established regarding causation?
The breach must be the proximate cause of injuries
## Footnote
For example, linking a missed diagnosis directly to a patient's subsequent condition can be challenging.
274
What types of damages are commonly considered in medical malpractice cases?
* Emotional distress
* Pain
* Suffering
## Footnote
These are often referred to as remunerative damages.
275
What are the three categories of claims of negligence against radiologists?
* Diagnostic errors
* Procedural complications
* Communication deficiencies
## Footnote
Each category represents different aspects where negligence can occur.
276
What is the most common cause of malpractice lawsuits against radiologists?
Alleged errors in diagnosis
## Footnote
Sensitivity of imaging in detecting disease can vary significantly.
277
What is hindsight bias in the context of medical malpractice?
The tendency to believe one would have predicted an outcome after knowing the actual result
## Footnote
This bias complicates the defense of malpractice cases.
278
What are the categories of negligent diagnosis claims?
* Failures of perception
* Failures of interpretation
* Combinations of both
## Footnote
These categories help classify the nature of diagnostic errors.
279
What types of errors can diagnostic errors in radiology be categorized into?
* Cognitive errors
* System errors
## Footnote
Cognitive errors relate to visual perception, while system errors relate to health system issues.
280
What factors can increase the likelihood of diagnostic errors in radiology?
* Lighting conditions
* Shift length
* Pace of interpretation
## Footnote
Awareness of these factors can help mitigate risks.
281
What is a common complication associated with invasive procedures in radiology?
Pneumothorax
## Footnote
Complications can serve as grounds for negligence claims if care is not exercised.
282
What should be included in documentation related to procedural complications?
* Details of care
* Prompt disclosure of events
* Ongoing communication
## Footnote
This can help in legal situations.
283
What does the doctrine of informed consent entail?
A patient's right to determine what shall be done with their body
## Footnote
It has been expanded to apply to various procedures beyond surgery.
284
What is routine communication in radiology?
Creation and delivery of written reports
## Footnote
The ACR Practice Parameter outlines formatting for these reports.
285
What is the purpose of a preliminary report in radiology?
To direct immediate patient management
## Footnote
It may be issued before the final report when urgent decisions are needed.
286
What are 'Level 1 results' in radiology communication?
Findings that warrant immediate or urgent intervention
## Footnote
These results are considered life-threatening and require prompt communication.
287
What should be documented in nonroutine communication?
* Date and time
* Person reporting
* Person receiving
* Summary of information conveyed
## Footnote
This ensures clarity and accountability.
288
What is informal communication in radiology?
Interpretations provided without a formal report
## Footnote
These can carry risks due to lack of documentation.
289
What privilege protects communications between clients and their attorneys in malpractice cases?
Attorney-client privilege
## Footnote
This privilege encourages full disclosure to attorneys.
290
What types of peer review communications are protected from legal discovery?
Communications occurring within established peer review processes
## Footnote
Informal conversations outside these processes are typically not protected.
291
What does DICOM stand for?
Digital Imaging and Communications in Medicine
292
What is the primary purpose of the DICOM standard?
Specifies protocols for display, transfer, storage, and processing of medical images
293
What type of data does the DICOM standard apply to?
Both pixel-based image data and metadata
294
What is contained in the DICOM header?
Information about the image, series, exam, patient, imaging facility, and scanner
295
What is the function of DICOM transactions?
Enable data to be queried, retrieved, and transmitted between systems
296
What is HL7?
International standards organization for the exchange, integration, sharing, and retrieval of medical information
297
What is the most widely implemented HL7 standard?
HL7 V2 messaging standard
298
What is the HL7 FHIR standard used for?
Allows software developers to use internet transactions to exchange medical data
299
What are ontologies in the context of medical imaging?
Formal collections of terms and their inherited or causal relationships
300
What is RadLex?
The largest radiology-specific lexicon containing more than 68,000 terms
301
What does PACS stand for?
Picture Archiving and Communications System
302
What are the basic components of PACS?
* Workstation
* Display
* Short-term storage
* Long-term archive
303
How does PACS communicate with imaging modalities?
Using DICOM transactions
304
What is a VNA?
Vendor-neutral archive for storing data from multiple types of DICOM images and non-DICOM data
305
What does RIS stand for?
Radiology Information System
306
What functions does a RIS manage?
* Order reconciliation
* Patient scheduling and tracking
* Communication with modalities and PACS
* Reporting
* Results notification
* Billing
307
What is the recommended ambient lighting level for reading rooms according to ACR-AAPM-SIIM?
25 to 50 lux
308
What is lossless compression?
Decreases redundant image information without losing content
309
What is lossy compression?
Discards unnecessary image information for greater size reduction
310
What are common repetitive strain injuries (RSI) for radiologists?
* Carpal tunnel syndrome
* Cubital tunnel syndrome
* DeQuervain tenosynovitis
311
What is the role of workflow in medical imaging?
Interoperability between PACS, RIS, EMR, and imaging modalities
312
What are downtime procedures in radiology?
* Disaster recovery (DR)
* Business continuity (BC)
313
What does de-identification of images involve?
Removing protected health information (PHI) from imaging examinations
314
What is the difference between de-identification and anonymization?
De-identification removes PHI but may allow re-identification; anonymization removes all identifiable data permanently
315
What is cybersecurity in the context of radiology?
Protection against ransomware attacks and ensuring data recovery
316
What is image segmentation?
Isolating or extracting a region of interest from an image
317
What is image registration?
Aligning one image set onto the coordinate space of another for comparison
318
What is deep learning?
A subfield of AI using multi-layered neural networks for data analysis
319
What is supervised learning?
Exposes an algorithm to labeled training data to evaluate prediction accuracy
320
What is unsupervised learning?
Exposes an algorithm to unlabeled data and organizes it without predefined categories
321
What are the challenges in deploying AI for radiology?
* Understanding model results
* Reliable performance in various settings
* Integration into clinical workflow
322
What is bias in AI?
Discrepancies due to training data, model architecture, or user conclusions
323
Order of process changes which result in lowest consistency in outcome to highest consistency in outcome
Process which rely on education and feedback, then those that rely on standardization of procedures, then those that rely on changes to infrastructure and organizational culture
324
What is minimal sedation/anxiolysis
Drug induced state to reduce anxiety, during which patient responds to verbal commands. Cognitive function and coordination are impaired but ventilators and cardiovascular fxns are not
325
Continuous monitoring of sedation includes what
Level of consciousness, respiratory rate, pulse oximetry, blood pressure, heart rate, cardiac rhythm and IV access
326
Reversal agent risk
If duration of effect is shorter than sedating agent, may relapse into deeper level of sedation
Consciousness and vitals should return to normal for 2 hrs prior to discharge
327
How can consent be documented
Consent form, note in patient’s medical record, recording on videotape, or similar permanent modality
328
What are the rules of ethics specifically applying to radiology as stated by ACR
1) professional limitations
2) reporting illegal or unethical conduct
3) report signature
4) participation in quality and safety activities
5) self referral
6) harassment
7) undue influence
8) agreements for provision of high quality care
9) misleading billing arrangements
10) expert medical testimony
11) research integrity
12) plagiarism
13) misleading publicizing
329
Which modality contributes most to the estimated medical ionizing radiation exposure to the US population?
CT contributes 49% of total estimated medical dose
330
Which of the following accounts for most of the naturally occurring radiation exposure to humans?
Radon gas is the primary source of naturally occurring radiation.
331
What condition is characterized by absent cavum septi pellucidi?
Septooptic dysplasia
## Footnote
Septooptic dysplasia is a congenital brain malformation associated with optic nerve hypoplasia and various endocrine abnormalities.
332
what is most sensitive for osteonecrosis
MRI
333
334
What is the recommended range of ambient lighting for an ideal reading room?
25 to 50 lux
## Footnote
This level of lighting is similar to standing under a street light at night in dark surroundings.
335
What is the recommended maximum gray value luminance for diagnostic monitors for nonmammographic interpretation?
At least 350 cd/m
## Footnote
This is crucial for ensuring adequate image quality in medical diagnostics.
336
What is the recommended maximum gray value luminance for diagnostic monitors for mammographic interpretation?
At least 420 cd/m
## Footnote
Higher luminance is essential for the clarity of mammographic images.
337
What is a Pareto chart used for?
To illustrate which causes occur most frequently
Document possible causes and frequency of those causes
## Footnote
It helps in prioritizing issues based on their frequency.
338
True or False: A Pareto chart can show the most frequent causes of problems.
True
339
Which ACR initiative includes specific recommendations for equipment specifications and settings
The ACR Technical Standards describe technical parameters that are quantitative or measurable. They often include specific recommendations for patient management or equipment specifications or settings.
340
What does the preeminence of the patient demand from radiologists?
Radiologists must place their patients’ interests first in all healthcare decisions.
341
True or False: The preeminence of the patient is always obvious in healthcare decisions.
False
342
What factors may cause deviation from the preeminence of the patient?
* Economics
* Overzealousness in implementing new procedures
* Overconfidence in abilities and knowledge
343
What threatens the preeminence of the patient according to the text?
Financially motivated self-referral by radiologists’ clinical colleagues.
344
Fill in the blank: The preeminence of the patient may seem obvious, but many factors including _______ can cause deviation.
[economics]
345
What is a consequence of overconfidence in our abilities and knowledge?
It may cause deviation from the preeminence of the patient.
346
List three factors that can lead radiologists to deviate from patient preeminence.
* Economics
* Overzealousness in implementing new procedures
* Overconfidence
